QB2 | Practice Exam #60 -> answers with explanation
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NCLEX-RN | QB2 | Practice Exam #60 (50 questions)
All 50 questions are randomized each time you take the test, and do not appear in the same order.
1. A patient with Alzheimer's disease has a fall, which results to a fracture of the right leg, after repair of the fracture the patient is discharged home with family with instructions of wound care, the family verbalizes that the patient has been doing well,which of the following instructions would the nurse give to the family?
- Instruct the family how to provide skin integrity
- Suggest to the family that if the stress is overwhelming , placement in a skilled nursing facility may be needed
- Suggest collecting the patient on a regular schedule and applying incontinence brief at all times
- Assess for the cause of incontinence and add an appropriate nursing diagnosis post and interventions
2. A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially?
- Warm the client.
- Maintain a patent airway.
- Administer thyroid hormone.
- Administer fluid replacement.
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3. A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing which problem?
- Hypercalcemia
- Peripheral neuritis
- Small blood vessel spasm
- Impaired peripheral circulation
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4. A 45 year-old woman is receiving chemotherapy for breast cancer. Two weeks after the initial treatment she telephoned the nurse at the cancer center and reports she has hair loss, nausea, tiredness, a body temperature is 38.1 C, and air hunger Which finding most likely indicates she needs to report the clinic?
- Pyrexia
- Nausea
- Hair loss
- Air hunger
5. The nurse is monitoring a client who is taking propranolol Which assessment finding indicates a potential adverse complication associated with this medication?
- The development of complaints of insomnia
- The development of audible expiratory wheezes
- A baseline blood pressure of 150/80 mm Hg followed by a blood pressure of 138/72 mm Hg after 2 doses of the medication
- A baseline resting heart rate of 88 beats/minute followed by a resting heart rate of 72 beats/ minute after 2 doses of the medication
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6. A patient scheduled for an abdominal aneurysm repair. This is what type of surgical intervention?
- Diagnostic
- Transplant
- Curative
- Palliative
7. Situation: Cletus, Age 72, is a widower with moderate Alzheimer s disease. Was brought to the home for the Aged by his married daughter. On admission, she says to the nurse, "1 never thought this would happen to us. I really feel guilty about bringing him here, I can't bear to part with him." Q. A client with Alzheimer's disease mumbles incoherently and rambles in a confused manner. To help redirect the client's attention, the nurse should encourage the client to:
- fold towels and pillowcases.
- play cards with another client.
- participate in a game of charades.
- perform an aerobic exercise.
8. Which vitamin should be administered with INH (isoniazid) in order to prevent possible nervous system side effects?
- Thiamine
- Niacin
- Pyridoxine
- Riboflavin
9. Nurse hazel receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?
- Liver disease
- Myocardial damage
- Hypertension
- Cancer
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10. A client with leukemia is receiving Trimetrexate. After reviewing the clients chart the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:
- Treat iron-deficiency anemia caused by chemotherapeutic agents
- Create a synergistic effect that shortens treatment time
- Increase the number of circulating neutrophils
- Reverse drug toxicity and prevent tissue damage
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11. When discussing breathing exercises with a postoperative client, Nurse Hazel should include which of the following teaching?
- Short frequent breaths
- Exhale with mouth open
- Exercise twice a day
- Place hand on the abdomen and feel it rise
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12. Important teaching for women in their childbearing years who are receiving antipsychotic medications includes which of the following?
- Increased incidence of dysmenorrhea while taking the drug
- Occurrence of incomplete libido due to medication adverse effects
- Continuing previous use of contraception during periods of amenorrhea
- Instruction that amenorrhea is irreversible
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13. A client in sickle cell crisis is admitted to the emergency department what are the priorities of care?
- Nutrition, hydration, electrolyte balance
- Hydration, pain management, electrolyte balance
- Hydration, oxygenation, pain management
- Hydration, oxygenation, electrolyte balance
14. When planning care for a female client using ritualistic behavior, Nurse Gina must recognize that the ritual:
- Helps the client focus on the inability to deal with reality
- Helps the client control the anxiety
- Is under the clients conscious control
- Is used by the client primarily for secondary gains
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15. Situation: Burn is cause by transfer of heat source to the body. It can be thermal, electrical radiation or chemical. Q. During the first 24 hours after thermal injury you should assess Sergio for:
- hypokalemia and hypernatremia
- hypokalemia and hyponatremia
- hyperkalemia and hyponatremia
- hyperkalemia and hypernatremia
16. A camp nurse is applying sunscreen to a group of children enrolled in swim classes. Chemical sunscreens are most effective when applied:
- Just before sun exposure
- Five minutes before sun exposure
- 15 minutes before sun exposure
- 30 minutes before sun exposure
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17. What is the most important postoperative instruction that nurse Kate must give a client who has just returned from the operating room after receiving a subarachnoid block?
- "Avoid drinking liquids until the gag reflex returns."
- "Avoid eating milk products for 24 hours"
- "Notify a nurse if you experience blood in your urine"
- "Remain supine for the time specified by the physician."
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18. A home care nurse visits a patient with a new-below-the knee amputation. The site of the incision is red, warm and tender with purulent yellow drainage. The patient has a new prescription for cephalexin (Keflex) and oxycodone (oxycontin). What would the nurse instruct the patient to do FIRST?
- Take oxycodone as soon as possible
- Take cephalexin as soon as possible
- Wash the incision site and apply bacitracin cream
- Wash the incision site and apply hydrocortisone
19. The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency?
- Cyanosis
- Arm edema
- Periorbital edema
- Mental status changes
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20. Situation: A nurse is working with an aggressive client in the psychiatric unit Q. Which of the following must be considered while planning activities for the depressed patient?
- Activities which require exertion of energy
- Challenging activities to get him out of his depression
- Structured activities that the client can participate
- Variety of unstructured activities
21. A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing respiratory assessment on this client?
- Stridor
- Crackles
- Wheezes
- Diminished
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22. A Community Health nurse is administering tuberculin skin tests purified protein derivative (PPD), which of the following time frames should the nurse tell the patient to return to the clinic for the test to be read?
- In 12-24 hours
- In 24-36 hours
- In 36-48 hours
- In 48-72 hours
23. After a client receives an IM injection, he complains of a burning pain in the injection site. Which nursing action would be best to take at this time?
- apply a cold compress to decrease swelling
- apply a warm compress to dilate the blood vessels
- Massage the area to promote absorption of the drug
- Instruct the client to tighten his gluteal muscles to enhance absorption of the drug
24. The nurse is caring for an elderly client in a long-term care facility. The client has a history of attempted suicide. The nurse observes the client giving away personal belongings and has heard the client express feelings of hopelessness to other residents. Which intervention should the nurse perform first?
- Setting aside time to listen to the client
- Removing items that the client could use in a suicide attempt
- Communicating a nonjudgmental attitude
- Referring the client to a mental health professional
25. The nurse is entering the room of a patient who is blind. The nurse should:
- Speak before touching the patient
- Talk to the patient using aloud tone
- Ask then patient questions that can be answered yes or no
- Stand directly in front of the patient while talking
26. Situation: A nurse is working with an aggressive client in the psychiatric unit Q. Carlo is acting out hostile and aggressive feeling by kicking the chairs in the room, the MOST effective way to deal with Carlo's behavior is initially to:
- Set limits on the behavior by verbal command
- Administer PRN tranquilizer
- Remove the chairs from the room
- Restrain the patient and place him in the "Isolation Room"
27. Situation: The question with regards to the OPERATING ROOM. Q. The OR team collaborates from the first to the last surgical procedure. Who monitors the activities of each OR suite?
- scrub nurse
- anesthesiologist
- circulating nurse
- surgeon
28. A patient to have an elective surgical procedure to repair an umbilical hernia. The patient is 68 year old, weighs 136 kg( 3001b), and has diabetic mellitus. Which of the following approaches would be the MOST beneficial in order to reduce the patient surgical risk?
- Monitor blood glucose level monthly
- Avoid fluid overload by restricting fluid
- Discourage any changes in routine before surgery
- Encourage weight reduction
29. A client is prescribed an eye drop and an eye ointment for the right eye. How should the nurse best administer the medications?
- Administer the eye drop first followed by the eye ointment.
- Administer the eye ointment first, followed by the eye drop.
- Administer the eye drop, wait 15 minutes, and administer the eye ointment.
- Administer the eye ointment, wait 15 minutes, and administer the eye drop.
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30. The nurse is assigning staff to care for a number of clients with emotional disorders. Which facet of care is suitable to the skills of the nursing assistant?
- Obtaining the vital signs of a client admitted for alcohol withdrawal
- Helping a client with depression with bathing and grooming
- Monitoring a client who is receiving electroconvulsive therapy
- Sitting with a client with mania who is in seclusion
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31. A postpartum client has a temperature of 101.4°F, with a uterus that is tender when palpated, remains unusually large, and not descending as normally expected. Which of the following should the nurse assess next?
- Lochia
- Breasts
- Incision
- Urine
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32. The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?
- I will drink 500mL of fluid or less each day.
- I will wear support hose.
- I will check my blood pressure regularly.
- I will report ankle edema.
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33. Which of the following symptoms would the nurse most likely observe in a client with cholecystitis from cholelithiasis?
- Black stools
- Nausea after ingestion of high fat foods
- Elevated temperature of 103 F (39.4 C)
- Decreased WBC count
34. The nursing assistant tells nurse Ronald that the client is not in the dining room for lunch. Nurse Ronald would direct the nursing assistant to do which of the following?
- Tell the client he'll need to wait until supper to eat if he misses lunch
- Invite the client to lunch and accompany him to the dining room
- Inform the client that he has 10 minutes to get to the dining room for lunch
- Take the client a lunch tray and let the client eat in his room
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35. A nurse is assessing a 5-month-old infant. The parents state that the infant is irritable, crying excessively, vomiting formula (not projectile), arching, and stiffening. Based on this assessment, what diagnosis should the nurse anticipate?
- Esophageal astresia withtracheoesophageal fistula
- Gastroesophageal reflux
- Hirschsprungs disease
- Celiac disease
36. Which of the following is the appropriate route of administration for insulin?
- Intramuscular
- Intradermal
- Subcutaneous
- Intravenous
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37. A client with persistent, severe schizophrenia has been treated with phenothiazines for the past 17 years. Now the client's speech is garbled as a result of drug-induced rhythmic tongue protrusion. What is another name for this extrapyramidal symptom?
- Dystonia
- Akathisia
- Pseudoparkinsonism
- Tardive dyskinesia
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38. When planning care with a client during the postoperative recovery period following an abdominal hysterectomy and bilateral salpingo-oophorectomy, nurse Frida should include the explanation that:
- Surgical menopause will occur
- Urinary retention is a common problem
- Weight gain is expected, and dietary plan are needed
- Depression is normal and should be expected
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39. A nurse has been visiting a bed-bound patient with decreased bowel mobility in the home for one month. The family tells the nurse that the patient is becoming incontinent of feces. The nurse evaluates the plan of care and notes which of the following intervention would MOST likely beneficial?
- An enema two times a week
- Increased fiber in the diet
- Aroutinebisacodyl (Dulcolax) suppository
- An enema three times a week
40. Situation: Mrs. Damian an immediate post op cholecystectomy and choledocholithotomy patient, complained of severe pain at the wound site. Q. Choledocholithotomy is:
- The removal of the gallbladder
- The removal of the stones in the gallbladder
- The removal of the stones in the common bile duct
- The removal of the stones in the kidney
41. A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply. 1. "I'm afraid of spiders." 2. "I keep reliving the robbery." 3. "I see his face everywhere I go." 4. "1 don't want anything to eat now." 5. "I might have died over a few dollars in my pocket" 6. "I have to wash my hands over and over again many times."
- 1,2,3
- 2,3,4
- 2,3,5
- 1,3,6
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42. The nurse is caring for a client post-myocardial infarction on the cardiac unit The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?
- BP 90/60
- Chest pain
- Increased anxiety
- Temp 98.6 F
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43. A client is experiencing spinal shock. Nurse Myrna should expect the function of the bladder to be which of the following?
- Normal
- Atonic
- Spastic
- Uncontrolled
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44. Situation: Cancer of the prostate is the leading cancer in Men other than skin cancer. The following questions will assess your knowledge and theoretical foundation in dealing with clients with prostate cancer. Q. In testing for the PSA, the nurse will collect which specimen?
- Blood
- Urine
- Feces
- Prostatic fluid
45. According to C.E. Winslow, which of the following is the goal of Public Health?
- For people to attain their birthrights of health and longevity
- For promotion of health and prevention of disease
- For people to have access to basic health services
- For people to be organized in their health efforts
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46. Situation: Margie has been diagnosed with Bipolar I disorder The client demonstrates extreme psychomotor agitation, flight of ideas, loud talking and elated mood. Q. During nurse patient interaction, Margie jumps rapidly from one topic to another This is known as:
- Flight of Ideas
- Clang association
- Ideas of reference
- Neologism
47. She takes pride in saying that the hospital has a decentralized structure. Which of the following is NOT compatible with this type of model?
- Flat organization
- Participatory approach
- Shared governance
- Tall organization
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48. According to her, Wellness is a condition in which all parts and subparts of an individual are in harmony with the whole system.
- Orem
- Henderson
- Neuman
- Johnson
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49. A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition?
- Rupture of the bladder
- The development of a vesicovaginal fistula
- Extreme stress caused by the diagnosis of cancer
- Altered perineal sensation as a side effect of radiation therapy
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50. An infertile woman has been diagnosed with endometriosis. She asks the nurse why that diagnosis has made her infertile. Which of the following explanations is appro- priate for the nurse to make?
- "Scarring surrounds the ends of your tubes preventing your eggs from being fertilized by your partner's sperm."
- "You are producing insufficient quantities of follicle-stimulating hormone that is needed to mature an egg every month"
- "Inside your uterus is a benign tumor that makes it impossible for the fertilized egg to implant."
- "You have a chronic infection of the vaginal tract that makes the secretions hos- tile to your partner's sperm."
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